www.ttconnect.gov.tt gortt wcm connect 6e3460004b2a0758b687fe63be472f22 help application form

8/13/2019 Www.ttconnect.gov.Tt Gortt Wcm Connect 6e3460004b2a0758b687fe63be472f22 HELP Application Form

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ALL QUESTIONS MUST BE COMPLETED ALL REQUESTED DOCUMENTS MUST BE ATTACHED

MINISTRY OF SCIENCE, TECHNOLOGY AND TERTIARY EDUCATION

Application Form

1.1 Name: _________________________________________________________________________________________________

Surname First Middle Title

1.2 Date of Birth (dd/mm/yy): _______ / _______ / _______ 1.3 Gender: Female Male

1.4 Country of Birth: ____________________________ Attach copy of Birth Certificate.

1.5 Trinidad and Tobago Passport Number: ____________________________

Trinidad and Tobago National ID Number: _________________________ Attach copy of Passport or National ID Card.

1.6 Address: ____________________________________________________________________________________

Town: ____________________________City:_____________________Country:__________________________

Attach Utility Bill for verification of address.

1.6a Mailing Address (if different from home address in 1.6 above):_________________________________________

_______________________________________________________________________________________________________

1.7 Telephone Contacts: Home: _____________ Cell: ______________ Work: ____________________

1.8 Email address: _____________________________________

1.9 Marital Status: Single Married Common Law Separated Divorced Widowed

1.10 Employment Status: Full-Time Part-Time Other (Seasonal, Casual) Not Employed

1.11 Dependant: Yes No

1.12 Applicant (and spouse, where applicable)

reside together separate residence with parents with relatives

1.13 If spouse is also a student, year of expected graduation ____________

2.1 Institution: Local Regional (Mona, Cave Hill, Bahamas etc) Other approved with special arrangements

2.2 Institution Name: _____________________________________________________________________________

2.3 Institution Address: ___________________________________________________________________________

Town:____________________________City:_____________________Country: __________________________

2.4 Institution Telephone No. ___________________________________

2.5 Student Registration No. ____________________________________

2.6 If Caricom Institution or Distance Learning programme, please provide Registrar’s/Foreign Student Advisor’s name:

____________________________________________________________________________________

2.7 Programme Name: ____________________________________________________________________

2.8 Programme Level:

Certificate Diploma Advanced Diploma Associate Degree

Bachelor’s Degree: BA BSc BEd BTech LLB

BEng DDS DVM MBBS Other _______

Professional Qualification

Postgraduate Diploma

Master’s Degree

Doctoral Degree

2.9 Are you registering/registered as a Full Time or Part Time student? Full Time Part Time

2.10 Duration of Programme (calendar years):

1 year or less 2 years 3 years 4 years 5 years 6 years

2.11 Programme Year for which you are seeking assistance:

Year 1 Year II Year III Year IV Year V Year VI

2.12 Academic year of the programme for which you are seeking assistance:

______________________________ to _______________________________

2.13 Address for residence during course of study (if different to address in 1.6 above):

_____________________________________________________________________________________

Town:____________________________City:_____________________Country: __________________________ 2.14 New Student Continuing Student

Continuing students: Attach Result Slip(s) for previous year and copy of completed Continuing Registration Form.

New Students: Attach copy of Acceptance Letter and copy of completed Registration Form (stamped by TLI).

SECTION 1—Applicant’s Personal Data

SECTION 2—Institution and Programme Data

1



3.1 Fill in Table 3.1 below.

Total Cost:

All expenses related to the programme must be listed below in the Total Cost column to enable an assessment of the overall cost

of studying for the period indicated in question 2.12.

Amount Already Covered:

Indicate the amount for which you have already determined/sourced coverage in the Amount Already Covered column.

Source of Coverage:

Indicate using the appropriate letter from the following list in the Source of Coverage column in table 3.1 below:-

A Bank Loan

B USGLF or SRLF

C Parents/Guardian

D Personal Funds from savings or salary

E Awards, Scholarships, Grants

F Other (please state) _________________________________________________

G GATE

Each entry must be accompanied with supporting documentation that is to be firmly attached to this application.

Where foreign currencies apply, indicate the foreign currency amount and the exchange rate used to determine the TT$ amount

entered in the table in the space under the item.

4.1 Number of persons in household: ________

4.1.1 Household Income Contributors (residing in the same location as applicant)

4.1.2 Other Household Members List in Table 4.1.2 below any members of the applicant’s household who are not employed, such as minors or disabled

household members.

Item Total Cost

TT$

Amount

Already

Covered TT$

Source Of

Coverage

A–G

Help

Assistance Sought

TT$

For Official Use

Amount

Approved TT$

Annual Tuition

Books

Accommodation

Airfare

Other Materials

Administrative

Expenses

Living Expenses

Other

Totals

SECTION 3—Tertiary Expenses

SECTION 4—Household Expenses

Name Age Occupation Relationship to Applicant

Name Age Status Relationship to Applicant

2

Table 3.1

Table 4.1.1

Table 4.1.2



4.1.3 Household Members excluding applicant pursuing tertiary education

List in Table 4.1.3 below any relevant member from Table 4.1.1 and/or 4.1.2.

4.2 Household Income

This includes salary, scholarship or award funds, benefit payments e.g. disability, welfare etc., child support, alimony, rental

income, other investment income etc. List these in Table 4.2 below.

Each entry must be accompanied by supporting documentation in the form of a pay slip, TD4, cheque stub, receipt,

bank statement etc.

4.3 Household Expenditure

This includes utility payments, loans, living expenses, pension plan deductions, health plan deductions, school fees, land

& building taxes, medical supplies etc. List these in Table 4.3 below.

4.4 Household Assets

These include property, motor vehicles, furniture, saving accounts, stocks, life insurance policies etc.

List these in Table 4.4 below.

Name Institution Programme Receiving Scholarship/

Bursary/Grant? Y/N

Name/Source Type of Income Annual Gross Annual Net of PAYE,

NIS and HSc

For Official Use

Total:

Item Average Monthly Cost Annual Cost For Official Use

Total:

Item Approximate Current Value For Official Use

Total:

Table 4.1.3

Table 4.2

Table 4.3

Table 4.4

3



4.5 Household Liabilities

These include mortgage loans, other loans etc. List these in Table 4.5 below.

4.6 Do you/did you have any contractual obligations with respect to Scholarships/Bursaries/Loans?

__________________________________________________________________________________________________ 4.7 If yes, describe the contractual obligations?

__________________________________________________________________________________________________

4.8 What arrangements have you made/will you make to fulfil existing contractual obligations?

__________________________________________________________________________________________________

4.9 References:

Name two responsible persons by whom confidential references about you can be obtained.

4.9 (i) Name:___________________________________________________________________________________________

Occupation: __________________________________________________________________________

Address:_________________________________________________________________________________________

Telephone Contacts: Home: _____________ Cell: ______________Work: _________________ 4.9 (ii) Name: __________________________________________________________________________________________

Occupation: ___________________________________________________________________________

Address:_________________________________________________________________________________________

Telephone Contacts: Home: _____________ Cell: ______________ Work: _________________

4.10 Are you willing to personally guarantee repayment of the approved loan in accordance with the repayment provision of

HELP? Yes No

4.11 Reference (a parent, legal guardian or sponsor):

Name: ________________________________________________ Age: _______

Address: ____________________________________________________________________________________

Town:____________________________City:_____________________Country: __________________________

Telephone Contacts: Home: _____________ Cell: ______________Work: __________________

Occupation:___________________________________________________________________________

Relationship to Applicant: _____________________________ _______________

• I declare that the information provided on this application is true and correct

• I am aware that this application will be subject to a thorough review and may be selected for a detailed audit by the Funding and

Grants Administration Unit of the Ministry of Science, Technology and Tertiary Education

• If selected for a detailed audit, I am committed to cooperating fully with the officers assigned to perform the audit

• I am aware that on application my credit or other information provided may be used, given to, obtained, verified, shared and

exchanged with others, including credit bureaus, mortgage insurers, registries, other approved companies and other personswith whom I have financial dealings as well as any other person, as may be permitted or required by law. I authorize any person

contacted in this regard to provide such information

• I am aware that a false declaration can be subject to a fine or summary conviction.

Student’s Signature: ___________________________ Date (dd/mm/yy): _____/_____/______

(If the student is under 18 years this agreement must be signed by the Parent, Guardian or other responsible person over age

18. In signing below the Parent, Guardian or other responsible person approves all the Student’s obligations stated herein and

constitutes a guarantee of the Student’s obligations.

Parent Guardian Signature:___________________________ Date (dd/mm/yy): _____/_____/______

GUARANTEE

The Ministry of Science, Technology and Tertiary Education is committed to treating the above information with strict confidence.

Item Approximate Balance Owing For Official Use

Total:

SECTION 5—Declaration

Table 4.5

4

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